Medical Claim Denials: An Overview

An introduction and overview to our important series, “Don’t Be Denied.” We cover “the basics” on medical insurance claim denials and the reasons behind them, introducing the concepts of appeal and the many methods that need to be followed in their pursuit.

Episode In Depth

Medical Claim Denials: An Overview

Welcome to the inaugural podcast of our “Don’t Be Denied” series. This series will

provide step-by-step directions for how to launch an effective appeal effort. For complete information us and our service offerings, please visit us at

The other title of this episode is “Denial is a River.”  Actually, the many means and methods of denial is more like a flood, but the pun doesn’t work with a flood. Let’s begin.

Over the coming months, we’ll discuss a variety of topics with one common purpose – to show you how to be a better advocate for yourself with healthcare providers and health insurance companies.  Importantly, and since our podcast is called “Don’t be Denied,” we will show you how best to resolve denials around appropriate medical care prescribed by health professionals but denied.

Actually, the many means and methods of denial is more like a flood, but the pun doesn’t work with a flood. Let’s begin.

Pity the poor employee who, upon starting their job, gets a company tour, is introduced to many strangers, given a slew of policies and procedures, has to sign a manual they probably won’t read and then – a booklet of benefit options which only skim the surface – in 30 pages.  Most will typically skip the enrollment guide, the online tutorial and the Summary of Benefits and Coverage, or SBC.  Some brave souls may ask to see the whole contract – if it is in their native language – and runs at least 150 pages.  Who really reads all this?  Probably only the people that wrote it — attorneys for the insurance company.

We are not here to bash insurance carriers.  We are also not here to necessarily defend some of their actions, either, though we well understand their position, given all our experience with them.  Instead, we are here to help you navigate the troubled and frustrating waters of denial, so you can reach shore safely and with the least amount of anxiety and trouble.

Here Are the basics:

Why do carriers deny claims?
What can you do about it?
What are your responsibilities and those of the insurance company?
Who can and should you call for assistance when issued a denial?
When do others need to get involved and who are they?
What are the roles of the broker, carrier, and your doctor in the process?

With all these denial layers, it gets pretty confusing.  It’s our goal to help you navigate through them and avoid the pitfalls that prevent you from getting the care to which you are entitled.

There are a lot, so I am going to read out the list:

  • There is no coverage for this condition in the contract.
    • Usually stated “this is not a covered benefit.”
  • There is no coverage if you are not using network providers
    • Called “out-of-network.”
  • We do not find this procedure, service, etc. to be medically necessary
    • Sometimes stated as “investigational or experimental.”
  • This drug is not covered because you did not attempt to use other options
    • Sometimes called “step-therapy.”
  • The surgery requires a second opinion and there is no record of it being done.
  • You (or your doctor) failed to get advance authorization for this procedure – called Prior Authorization.
  • The doctor used the wrong code for this service and as a result it is not covered – called a “coding error.”
  • The claim was filed after the required deadline – called filed past deadline
  • This is not an emergency, and therefore….
  • No referral was received (this is only an HMO problem).

While not a denial, there is another potential problem.  When you use an unlisted provider when a listed provider could have been used, the carrier reduces the payment amount allowed to this unlisted provider to the already discounted rate negotiated with a listed provider.

So, your claim has been denied, for one or more of the above reasons.  What can you do about it?  Well, the carrier will tell you there is a grievance or appeal procedure, but they have to say this.  The problem is that grievance is really only being made against the carrier if they failed to follow their procedure.  Now you have wasted another 30 days to find out the carrier was correct – based on the information and circumstances they were presented.

Next Steps:

  1. Gather all your information like doctor’s notes, lab results, X-Ray, or other imaging records (MRI, CT, ultrasound, etc.).
  2. Try to understand what the carrier may be missing or needs.
  3. Carefully review the health plan’s appeals process.
  4. Make sure to keep good records of all the steps taken, like to whom you spoke on the phone, what your provider’s office has done or sent.

Who would help you here?  The Human Resources or your Office Manager at work?  Frankly, they don’t always have the skills or experience to deal with the carrier.

Should you call the carrier directly?  Good luck with that.  Just be sure to find something entertaining to do while you’re on hold waiting for them to transfer you to another person.

You’ll be transferred multiple times to different people, some of whom will not be helpful.

When this happens, be sure to take good notes:  with whom did you speak, the date, time, what was said, what else might be needed.  If possible, get their telephone extension so you can contact them in the future and to establish a good working relationship which may be helpful in moving forward.  Start the conversation with what the problem and is how can you help me to resolve it.

This is the time when you understand the need for a professional team, and there are only two people on the team:

  1. Your broker (the broker for your employer’s health plan)
  2. Your doctor, or a medical advocate

And guess what – you have them right here on this podcast.

Your broker is the one who has a relationship with your insurance company – called the carrier.  They tend to have several, or maybe hundreds, of clients with the same carrier.  Therefore, a call from the broker will carry more weight than you, your doctor, or your employer.  Plus, they know how the system works and can understand often times confusing language of the carrier, seen in your denial letter.  Use them.

It’s important to understand that your doctor typically will not be of any direct help, except to write the formal appeal letter which needs to include all the necessary medical information.  That’s because your doctor is often overwhelmed, especially since the onset of the COVID pandemic.  As such, you can expect that the denial letter can be delayed.  To avoid this delay, you may be better off bringing in a medical expert that is paid to proceed…and quickly.

We are experts in this area – or we wouldn’t be running these podcast episodes. There are also a number of independent services available, which we post on our website for reference.

To get in touch with your broker, it’s best to contact your office or HR manager. They often can make this happen.  Have them contact the broker first to let them know you will be calling.  You may not reach the broker themselves, but rather a customer service representative that works for the brokerage.

When you speak to a customer service rep (or anyone involved for that matter).  It’s best to be clear with them about what your request is and what you will provide.  Be sure to get their name and contact information.  It is often best and quickest to send them the necessary information electronically and copy the broker and your office or HR manager on the communication but keep the hard copy for yourself.  Then follow up – did they get it, do they understand what you have sent, do they need anything else, and when can you expect a response?

Above all, be persistent, but not overly aggressive.  Also be timely in what’s asked fo you and expect reasonable timeliness on their part.  Make sure you feel comfortable that they understand what you’ve said and what you’re requesting.  Don’t assume anything, and put everything, and we mean everything, in writing.

Sometimes the response will be swift – the answer is no, and here is the reason why.

That’s unfortunate, but if they are definite, there may not be much that can be done.  Often, there is some daylight showing, and they can instruct you as to next steps and expectations.

Follow their instructions – and, as always, document all of it.

It’s not a guarantee, but it’s a start, and it’s often the only way to proceed.

Information about Medical Advocacy:

If a medical advocate is required, the broker or their office can suggest a specific advocate or have the resources to do so.  Medical advocacy is often required when there is a denial based on medical necessity, or to define a service that is considered to be an emergency, or why a specialist not in the network was used.  To be clear, a sore throat, earache, sinus pain and a headache without other signs or symptoms is generally not an emergency.  Health plans will want you to first call your doctor for advice.  In some instances, you may be referred to what is considered to be a lower level of care – meaning less expensive – urgent care or after-hours clinic. Evening pediatric clinics are a good example.

Brokers are paid to work on behalf of an organization AND their employees, but not all of them got the memo. If they do not respond to you, contact your employer and register your complaint.  This is YOUR coverage, provided for YOUR protection.  What good Is the protection (especially if you are paying any part of the premium) if it’s not meeting your needs?  Some legal issues may be involved here, but let’s not get into them.  Let’s just say that the broker is paid to provide service – so if they are not providing the service, your employer should find someone who will.

This has been a basic introduction to the problems facing you in terms of coverage,

contracts and control over your medical – and financial – fate.  It is the first part in a

series, which will be, in order:

  • Understanding the top reasons for coverage denial
  • A Medical primer – important information you need to know about your health plan
  • How to Choose a Medical Health Insurance Plan
  • Do’s and Don’ts for filing an appeal
  • How to be a partner in your medical care
  • Demystifying medical necessity
  • Pharmacy management
  • Understanding Medicare vs. your employer plan
  • The pros and cons of Health Maintenance Organizations (HMO)

Please note that there are podcasts directed at employer concerns only, also listed on our web site.

Look for regularly appearing blogs on our site:

Please join us in our future broadcasts.  Your comments and suggestions of other possible topics are welcome.

Our review services to assist your appeal efforts when there’s been a denial of payment for medical services are readily available. For details on this special service please contact us through our web site as noted above.